Understanding Patient Safety

Presented by Dr. Redouane Bouali

Canadian Patient Safety Institute (CPSI)June 10th, 2010

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To provide national leadership in building and advancing a safer Canadian health system

Mission

VisionWe envision a Canadian health system where:

• Patients, providers, governments and others work together to build and advance a safer health system;

• Providers take pride in their ability to deliver the safest and highest quality of care possible; and

• Every Canadian in need of healthcare can be confident that the care they receive is the safest in the world.

A Sad Story

Noisy place!!

• 65 years patient, in ICU being dialyzed

• Two nurses signing over• Patient experienced an

arythmia • No body noticed the ECG

strip....• No body could hear the

alarm Bell

KCI bed Rep

• He interrupted the nurses sign off and asked if he can bring his bed.

• The nurses suddenly realized that the patient was in cardiac arrest.....

• It was too Late!!!

Nosocomial infection outbreak

• Burn Unit• Experienced outbreak• MRSA and VRE

Serious concerns....

Security control at the front door

Hand Washing Mandatory!!!!

• Line infection!!!!

• A BIG CONCERN!!!

Results: Catheter infections

A very poor communication

• 24 years old man medical student

• Visited ER for abdominal pain

• Discharged after 36 hours with diagnosis of Gastritis.

• Patient went again to the ER for the same problem

• Patient insisted to go home because he had important test to do at the University

• Patient went to his hometown... Operated the same night for Appendicitis (After 10 days!!!)

Poor communication • Patient two days post op when was

authorized to go home , while walking in the parking crashed!!!!

• Died after 2 hours of CPR

• Parents devastated asked several times for an explanation (head of Surgery, head of Emergency, in the two hospitals ....)

• Finally after few months they went to the Media,,,,,,

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Overview

• Introduction to Patient Safety

• Systems vs. Person Approach

• The Safety Competencies

• The Role of the Clinician, Team and Patient

• Strategies to Improve Patient Safety

• Conclusion

Background

• The “Quality in Australian Health Care Study” (1995)

• The U.S. Institute of Medicine published the report “To Err is Human” (1999)

• The British Report, “An Organization with a Memory” from the National Health Service (2000)

• National Steering Committee on Patient Safety’s “Building a Safer System” (2002)

• The Canadian Adverse Events Study (2004)

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Canadian Adverse Events Study

Adverse Event (AE) is defined as:

“an unintended injury or complication that results in

disability at the time of discharge, death or

prolonged hospital stay and that is caused by health

care management rather than by the patient’s

underlying disease process.”

Baker GR, Norton PG, Flintoft V, Blais R, Brown A, Cox J et al. (2004).

The Canadian Adverse Events Study: The incidence of adverse events among hospital patients in Canada. CMAJ, 170(11), 1678-1686.

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Findings:• 3,745 charts reviewed

• ~7.5% of hospital admissions involve adverse event; 37% of adverse events preventable

Extrapolation:• Of ~2.5 million hospital admissions in Canada in 2000…

…185,000 experienced 1 or more adverse events

…70,000 of the 185,000 were determined to be preventable

…between 9,000 and 24,000 deaths due to adverse events could have been prevented

Canadian Adverse Events Study

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Extra hospital days associated with adverse events

Deaths among patients with preventable adverse events

Canadian Adverse Events Study

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What We Know

Canadian Institute for Health Information (2004)

• One in ten adults contract infection in hospital.

• One in ten patients receive wrong medication or wrong dose.

• More deaths after experiencing adverse events in hospital than deaths from breast cancer, motor vehicle and HIV combined.

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Study Date of admission

Number of hospital admissions

Adverse event rate (% admissions)

California Insurance Study

1974 20864 4.65 *

Harvard Medical Practice Study

1984 30195 3.7

Utah-Colorado 1992 14052 2.9

Australian 1992 14179 16.6

United Kingdom 1999 1014 10.8

Denmark 1998 1097 9.0

New Zealand 1998 6579 11.2

France ** 2002 778 14.5

Canada 2000 3745 7.5

Epidemiology of Harm

World Health Organization. (2004). World Alliance for Patient Safety: Forward programme 2005. Geneva, Switzerland: World Health Organization. Retrieved from http://www.who.int/patientsafety/en/brochure_final.pdf

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Definitions

Patient Safety - The reduction and mitigation of unsafe acts within the healthcare system through the use of best practices shown to lead optimal patient outcomes.

(Canadian Patient Safety Dictionary, 2003)

Adverse Events - Unintended injuries or complications that are caused by health care management, rather than the patient’s underlying disease, and that lead to death, disability at the time of discharge, or prolonged hospital stays.

(Baker et al., 2004)

Harm - An outcome that negatively affects a patient’s health and/or quality of life.

(Canadian Disclosure Guidelines, 2008)

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Adverse Events

• Delayed or missed diagnoses• Medication errors• Wrong side surgery• Wrong patient surgery• Equipment failure• Patient identity• Transfusion errors• Mislabeled specimen• Patient/resident falls• Time delay errors• Laboratory errors • Radiology errors• Procedural error

• Lost, delayed, or failures to follow up reports

• Retention of foreign object following surgery

• Contamination of drugs, equipment

• Intravascular air embolism• Failure to treat neonatal

hyperbilirubinemia• Stage lll or lV pressure ulcers

acquired after admission• Wrong gas delivery• Deaths associated with restraints

or bedrails• Sexual or physical assault

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Adverse Events vs. Critical Incidents

• Not all negative patient outcomes are “adverse events”

• Not all adverse events are “critical incidents”

Critical Incidents

Adverse

Events

Negative Outcomes

Critical incidents are the most

serious preventable adverse events.

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What Patient Safety Is and Is Not

• It is NOT what most of us were thinking about 10 years ago

• It is NOT what ‘we have always done’• It is the most significant change in the

healthcare system in over a century• It is a new applied science• It has forever changed the face of modern

healthcare

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Dangerous (>1/1000)

Regulated

Number of encounters for each fatality1 10 100 1,000 10,000 100,000 1,000,000 10,000,000

Tota

l L

ives

Lost

per

year

10

100

1,000

10,000

100,000

Driving

Commercial airlines

Firearms

Bungee Jumping

Rock Climbing for 25 hrs

Ultra-safe (<1/100K)

Coal Mining

Offshore Industry

truckers constructio

n

timber

15,000 deaths/yr

Hospitalization

Risky Activities (Adapted by Dr. Philip Hebert)

Scuba diving

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In health systems, the challenge is to change the environment from one of crisis and blame to that of

learning and improvement.

The Challenge

Emory Center on Health Outcomes & QualityPartnership for Health & Accountability, July 2004

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Determinants of Adverse Events

•The System•The People

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Most problems are found in processes, not in people. 

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• A system can be described as:A grouping of components, such as resources and organization (structure) that act together (process), to achieve a particular result (outcome).

(Canadian Patient Safety Dictionary, 2003)

• “Clearly certain structure is needed; and equally clearly, there is no way to change outcome except through changing process, since outcome ‘tells on’ process.”

Slee VN, Slee DA & Schmidt HJ (1996). Slee’s Health Care Terms, 3rd edition.

St. Paul, MN: Tringa Press.

A System Perspective

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Sources of System Error

• Overall culture

• Education / training / experience

• System design / engineering

• Resource availability

• Demand / volume

• Throughput impedance

• Shift-work schedules

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The Systems Approach

Reason, J., (2000), BMJ (320), 768.

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The Systems Approach

“…though we cannot change the human condition, we can change the conditions under

which humans work.”

Reason, J. (2000). Human error: Models and management. BMJ, 320(7237), 768-770.

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The Person Approach

• Historically focused on individual performance and not system issues

• Front line staff often not involved in the review of an adverse event

• Partial or incomplete “solutions” that do not fully resolve the underlying cause and leave the organization vulnerable to reoccurrence of the event

• Fear of reprisals drives important information underground

What about professional accountability?

Does a “system” approach mean that individual practitioners are not accountable for their actions?

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Sources of Personal Error

• Skill-based errors

•

• Rule-based errors

• Knowledge-based error

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The Person Approach

“Incompetent people are 1% of the problem. The other 99% are good people trying to do a good job who make very simple mistakes and

it's the processes that set them up to make these mistakes.”

Dr. Lucian Leape, Harvard School of Public Health

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Person vs. Systems Approach

Person

• Errors are the result of human failures

• Humans generally perform flawlessly

• Perfect performance is the expectation

• Use retraining and punishment to root out “bad apples”

Systems

• Begin with the premise that anything can and will go wrong

• Don’t expect humans to perform perfectly

• Design systems accordingly in a proactive way

• Collective preoccupation with possibility of failure

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The Safety Competencies

Domain 1

Contributing to a culture

of patient safety

Definition: A commitment to applying core patient safety knowledge, skills and values to everyday work

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Shared Accountability-Just Culture-

“…it is about creating a reporting environment where staff can raise their hand when they have seen a risk or made a mistake…..where risks are openly discussed between managers and staff.”

“…while we as humans are fallible, we do generally have control of our behavioural choices.”

“…good system design and good behavioural choices of staff together produce good results. It has to be both.”

Marx D, Comden SC, Sexhus Z (2005). Our inaugural issue – in recognition of

a growing community.The Just Culture Community News and Views, 1(1).

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Safety Culture

Excessive blame prevents recognition of error, impedes

learning and effective action to improve safety.

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Safety Culture

• “Join us in converting a culture of blame that hides information about risk and error into a culture of safety that flushes out information to prevent patient injuries.”

(Leape et al, 1998)

• “A somewhat lethal cocktail of impatience, scientific ignorance and naïve optimism may have dangerously inflated our expectations of safety culture.”

(Cox & Flin, 1998)

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Culture as Awareness

• Awareness of error and harm

• Willingness to discuss openly

• Open and fair culture

• Open disclosure

• Essential foundations

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Culture

• Teamwork• All focused on accomplishment of mutual

goals• Aim for high-quality performance• When something goes wrong…

– The focus is on what happened, rather than “who did it”

– Atmosphere of how do we find the issues / weaknesses and solve them

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The Safety Competencies

Domain 2

Work in teams for patient safety

Definition: Working within interprofessional teams to optimize patient safety

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Teamwork in Healthcare

• Healthcare must “establish team training programs for personnel in critical care areas . . . using proven methods such as the crew resource management training techniques employed in aviation”

(Kohn et. al, 2000)

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The Safety Competencies

Domain 3

Communicate effectively

for patient safety

Definition: Promoting patient safety through effective health care communication

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Communication / Team WorkWhy is it critical?

• Nearly all instances of unexpected adverse events involve communication failures

• Joint Commission sentinel event data -more than 2400 serious case analysis revealed communication failures were root cause in over 70%

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The Safety Competencies

Domain 4

Manage safety risks

Definition: Anticipating, recognizing and managing situations that place patients at risk

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Clinicians Create Safety

• Err on the side of safety – speak up and ask questions. Be safe first and brave afterwards.

• Be obsessive about hand washing. Be very aware of why we need to do this and less irritated about the time it takes.

• Have enough humility to recognize when you are out of your depth. Be willing to ask for help and receive help.

• Assess the situation and Be prepared to Complete the task.

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Teams Create Safety

• Make it clear what protocol or plan is being used.

• Messages and communications are acknowledged and repeated by those who receive them.

• Team members are aware of other’s actions and are ready to step in to support and assist.

• Team members support and monitor each other.

• Speak up when a patient is at risk.

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Patients Create Safety

• Speak up if you have questions of concerns, and if you don’t understand, ask again. It’s your body and your health, you have a right to know.

• Pay attention to the care you’re receiving. Make sure you’re getting the right treatments and medications. Don’t assume anything.

• Notice whether your caregivers have washed their hands. Don’t be afraid to remind them to do this.

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The Safety Competencies

Domain 5

Optimize human and

environmental factors

Definition: Managing the relationship between individual and environmental characteristics to

optimize patient safety

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Strategies to ImprovePatient Safety

• Hand hygiene

• Human factors engineering

• Safer Healthcare Now interventions• Improved care for Acute Myocardial Infarction• Prevention of central-line associated bloodstream infection• Medication reconciliation (Acute care/Long-term care)• Rapid response teams• Prevention of surgical site infections• Prevention of ventilator-associated pneumonia• Antibiotic resistant organisms (MRSA)• National collaborative on falls in long-term care• Venous thromboembolism

• Governance for safety and quality

10 Patient Safety Tips-Healthcare Professionals-

Communication:

1. Introduce yourself to your patients and let them know that you invite them to bring any concerns to your attention

2. Don’t allow patient and family concerns to go unresolved

3. Listen! Listen! Listen! 4. Maintain Situational Awareness (be alert,

follow your intuition)5. Participate in the implementation of a

common communication tool (e.g. SBAR)

Behaviours / Competencies:

6. Use recommended patient safety practices

7. Understand where and how to report adverse events

8. Participate in the testing of new devices

9. Be aware of your own limitations (e.g. fatigue, biases)

10. Seek out information about patient safety and incorporate it into your practice

10 Patient Safety Tips-Healthcare Professionals-

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The Safety Competencies

Domain 6

Recognize, respond to and disclose adverse events

Definition: Recognizing the occurrence of an adverse event or close call and responding effectively to

mitigate harm to the patient, ensure disclosure, and prevent recurrence

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• Definitions

Understanding Harm

Canadian Disclosure Guidelines CPSI

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Safety is in Your Hands

We will NOT solve the problems of safety

by assuming they are “just the risks” inherent in healthcare or by blaming someone.

Neither will solve the issues.

ONLY THROUGH OUR SYSTEMATIC EFFORTS CAN WE IMPROVE SAFETY FOR THE

PATIENTS, CLIENTS, AND RESIDENTS THAT WE CARE FOR

CPSI - Strategic Direction

• Click to ad text

CPSI - Areas of Focus

----------------------------------------------------------

EducationExecutive Patient Safety Series

SimulationHalifax Conferences

Canadian Patient Safety Officer CoursePatient Safety

Competencies

ResearchMental health

Home careLong Term Care

Building Capacity through Research

Interventions & ProgramsWorld Health Organization High 5’s

Patients for Patient SafetyHuman Factors

Culture of Patient SafetyCanada’s Hand Hygiene Campaign

Safer Healthcare Now!

Tools & Resources Root Cause Analysis

Electronic Health RecordCanadian Disclosure GuidelinesCanadian Adverse Event Reporting

and Learning SystemSafe Surgery Checklist

What more could CPSI bring?

Contribution to physician engagement

Safe Surgery Checklist – done!

Safe Prescribing Checklist- potential?

Safety/Pharma clips – potential?

Système et processus intégrés

hôpitalBureau/unité

maison

dossier patient

Futurfin 2010

VPN

recherche

envois HL7

Réseau interne Externe à l’hôpital

ADT

Pharm

LABS

Saisie de données manuelles est réglée par des gestes normaux du

personnel médical

• Valeurs et alertes personnalisées par l’utilisateur• changements/mise à jour automatiques

Seuil critique

Avertissement

Retour à une norme acceptable

Norme acceptable

personnalisablespersonnalisables

Évolution des 10 dernières meures

Évolution des 10 dernières meures

Ventilé, Cathéters, Microbiologie, Labos Ventilé, Cathéters,

Microbiologie, Labos

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Summary

• Patient safety is everyone’s responsibility

• Understanding the problem is the first step towards improvement

• When errors are viewed as an opportunity

for improvement rather than punishment, patients will benefit

Vincent et al, (1998). BMJ, 316, 1154-7.

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Take Home Message

“…there are some patients we cannot

help, there are none we cannot

harm...”

Arthur Bloomfield, M.D.

Quality of Healthcare in America Project 2003

-----Dr. Ken Stahl

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Thank You…